Reply to the Letter to the Editor: Editorial: It's More Than Burnout—The Moral Injury Crisis in Orthopaedic Surgeons

To the Editor,

I would like to thank Drs. Coleman and Iobst for continuing the discussion on moral injury and burnout in medicine [2]. There is no question that the causes are multifactorial, and I covered only a few of them in my editorial [3]. I think we are in complete agreement on this, and their letter amplifies some of the issues I did not have the space to cover. My main goal was to emphasize that the focus of moral injury and burnout should shift away from blaming the physician for not being sufficiently resilient and, instead, shift toward systemwide solutions to improve the conditions of the practice of medicine, which the letter writers have expanded on and clarified.

Their references [1, 4] nicely amplified the neuropathology of how a lack of control affects our nervous system. Unlike many professions, however, we as orthopaedic surgeons (and many other physicians) do not have control of our work environments. The current system is not designed to let us take a day off (or even rest) if we feel stressed or tired. Pilots, for instance, are not allowed to fly after a they’ve exceeded a specified number of hours, and although residents have duty hours restrictions, attending physicians do not. When the increasing administrative burdens are added to our daily schedule—many of which could be handled by others in the health system or eliminated completely—the stress we can’t control further increases. My intent was not to imply that moral injury was the predominant contributing factor to physician dissatisfaction, but that it is an important one that has received little attention, at least in the orthopaedic world. I believe it deserves more.

We do need comprehensive strategies that involve the physician, hospital leadership, and the healthcare system’s infrastructure if we are to make substantive improvements. If we don’t change the work environment and mitigate the administrative stresses and burdens placed on physicians, we will continue to experience high levels of burnout and moral distress. Having discussion groups and becoming more aware is a very important starting point. We must have honest conversations with medical students and residents about work-life balance, recognizing that we are not invincible nor infallible, and that sometimes we need help. We must stop stigmatizing the act of asking for help when we need it. Surgeons are particularly reluctant to seek such help. We need to recognize that this unspoken code Coleman and Iobst mention [2] should be put into perspective while we still provide appropriate care for our patients. Wellness classes and yoga may be important in alleviating the distress doctors face and are valuable adjuncts. But many of us currently don’t have the luxury of taking time when we need or want to engage in these activities or even simply to step away for a few moments of contemplation during a typical busy day. Some healthcare systems may have programs to combat this lack of control, but most systems do not. We need to work collaboratively so that the system, and not just the individual physician, bears the responsibility to change.

In conclusion, I am in complete agreement with Drs. Coleman and Iobst. I appreciate their ideas on how to delve into solutions beyond some broad principles, and I agree that these solutions may differ by practice and/or institution. I am hopeful that my editorial [3], along with their observations and specific recommendations, will lead to some realistic solutions for the current dilemma, which is hurting physicians, their patients, and the safety of the healthcare system.